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			<td style="width: 10%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Zone :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textinput_tag name=&quot;7bf17f62&quot; data_label=&quot;Zone&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Zone&quot; maxlength=&quot;40&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Certificat d&#39;urbanisme :</span></td>
			<td style="vertical-align: middle; width: 20%; text-align: right; white-space: nowrap;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;4567581f&quot; data_label=&quot;Certificat d&#39;urbanisme&quot; data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Bornage effectu&eacute; par un g&eacute;om&egrave;tre :</span></td>
			<td style="vertical-align: middle; width: 20%; text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;9033c3d7&quot; data_label=&quot;Bornage effectu&eacute; par un g&eacute;om&egrave;tre&quot; data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Acc&egrave;s au terrain :</span></td>
			<td style="vertical-align: middle; width: 20%; text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;1e3c9219&quot; data_label=&quot;Acc&egrave;s au terrain&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Acc&egrave;s au terrain&quot; data_choices=&quot;Public|public; Priv&eacute;|priv&eacute;;&quot; %}</span></td>
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</table>

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			<td style="width: 14%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">N&deg; de cadastre :</span></td>
			<td style="width: 17%;">{% textinput_tag name=&quot;42f6b59c&quot; data_label=&quot;n&deg; de cadastre&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;n&deg; de cadastre&quot; maxlength=&quot;20&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 11%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">R&eacute;f. section :</span></td>
			<td style="width: 17%;">{% textinput_tag name=&quot;7d02dfc6&quot; data_label=&quot;r&eacute;f section&quot; data_map_field=&quot;nomap&quot;&nbsp;data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 21%; vertical-align: middle;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Surface du terrain en m&sup2; :</span></td>
			<td style="vertical-align: middle; width: 25%;">{% textinput_tag name=&quot;31b9b8e6&quot; data_label=&quot;Surface du terrain en m&sup2;&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Surface du terrain en m&sup2;&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lotissement :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;8ddd8072&quot; data_label=&quot;Lotissement&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Lotissement&quot; data_choices=&quot;OUI|oui; NON|non;&quot; %}</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Permis d&#39;am&eacute;nager :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;fd0e2e11&quot; data_label=&quot;Permis d&#39;am&eacute;nager&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Permis d&#39;am&eacute;nager&quot; data_choices=&quot;OUI|oui; NON|non;&quot; %}</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">D&eacute;claration pr&eacute;alable :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;2653d63f&quot; data_label=&quot;D&eacute;claration pr&eacute;alable&quot; data_map_field=&quot;nomap&quot;&nbsp;data_choices=&quot;OUI|oui; NON|non;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Cahier des charges :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;e91c8694&quot; data_label=&quot;Cahier des charges&quot; data_map_field=&quot;nomap&quot;&nbsp;data_choices=&quot;OUI|oui; NON|non;&quot; %}</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">R&egrave;glement du lotissement :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;5d6b5aa2&quot; data_label=&quot;R&egrave;glement du lotissement&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;R&egrave;glement du lotissement&quot; data_choices=&quot;OUI|oui; NON|non;&quot; %}</span></td>
			<td style="text-align: right;">&nbsp;</td>
			<td>&nbsp;</td>
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			<td style="vertical-align: middle; width: 6%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Lot(s) :</span></td>
			<td>{% textinput_tag name=&quot;390d7a3e&quot; data_label=&quot;Num&eacute;ros de lots&quot; data_map_field=&quot;parcel_numero&quot; data_help=&quot;Num&eacute;ros de lots&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: middle; width: 19%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Surface de plancher :</span></td>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;8ae9eadd&quot; data_label=&quot;surface de plancher&quot; data_help=&quot;Surface de plancher&quot; maxlength=&quot;50&quot; data_map_field=&quot;nomap&quot;&nbsp;data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;5103fce0&quot; data_label=&quot;Parcellaire ou R&eacute;partie&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Parcellaire ou R&eacute;partie&quot; data_choices=&quot;Parcellaire|Parcellaire; R&eacute;partie|R&eacute;partie;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Le terrain est-il libre de toute occupation :</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;446ad7d6&quot; data_label=&quot;Terrain libre de toute occupation&quot; data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Si non, pr&eacute;ciser :</span></td>
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			<td>{% textarea_tag name=&quot;005968da&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_map_field=&quot;nomap&quot;&nbsp;data_label=&quot;Occupation du terrain&quot; data_help=&quot;Occupation du terrain&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Le terrain est-il libre de tout contrat (bail &agrave; ferme, droit d&#39;usage,&nbsp;panneau/pub) ?</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;ee9a2df5&quot; data_label=&quot;Terrain libre de tout contrat &quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Terrain libre de tout contrat &quot; data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Si non, pr&eacute;ciser :</span></td>
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			<td>{% textarea_tag name=&quot;62d25ee7&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Contrat&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Contrat&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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<p style="text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Viabilit&eacute;s :&nbsp;</span>{% checkbox_tag name=&quot;a2450cf8&quot; data_map_field=&quot;nomap&quot;&nbsp;data_label=&quot;Eau&quot; data_help=&quot;eau&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"> Eau </span>{% checkbox_tag name=&quot;322d3c13&quot; data_label=&quot;Electricit&eacute;&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Electricit&eacute;&quot; %}&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Electricit&eacute;&nbsp;</span>{% checkbox_tag name=&quot;8e5a43a7&quot; data_label=&quot;Gaz&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Gaz&quot; %}&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Gaz&nbsp; </span>{% checkbox_tag name=&quot;5f0c2cfe&quot; data_label=&quot;T&eacute;l&eacute;com&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;T&eacute;l&eacute;com&quot; %}&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">T&eacute;l&eacute;com&nbsp; </span></p>

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			<td style="vertical-align: top; width: 10%;">{% checkbox_tag name=&quot;326cfbf0&quot; data_label=&quot;Autre viabilit&eacute;&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Autre viabilit&eacute;&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Autre :</span></td>
			<td>{% textarea_tag name=&quot;e26c7551&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autre viabilit&eacute;&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Autre viabilit&eacute;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td colspan="4" style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">La distance en m&egrave;tres pour chacun de ces r&eacute;seaux :</span></td>
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			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Eau :</span></td>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Electricit&eacute;</span><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"> :</span></td>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Gaz :</span></td>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">T&eacute;l&eacute;com&nbsp;</span>&nbsp;:</td>
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			<td style="vertical-align: middle; width: 25%;">{% textinput_tag name=&quot;610ab297&quot; data_label=&quot;Distance Eau&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Distance Eau&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 25%;">{% textinput_tag name=&quot;99a57d79&quot; data_label=&quot;Distance Electricit&eacute;&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Distance Electricit&eacute;&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 25%;">{% textinput_tag name=&quot;422f0084&quot; data_label=&quot;Distance Gaz&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Distance Gaz&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 25%;">{% textinput_tag name=&quot;e55131ef&quot; data_label=&quot;Distance T&eacute;l&eacute;com&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Distance T&eacute;l&eacute;com&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="vertical-align: top; width: 10%;">{% checkbox_tag name=&quot;35b16d99&quot; data_label=&quot;Autre distance&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Autre distance&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&nbsp;Autre :</span></td>
			<td>{% textarea_tag name=&quot;db439641&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autre distance&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Autre distance&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-size:18px;"><span style="font-weight:900;"><span style="font-family: ITCAvantGardePro;">&Eacute;tat des&nbsp;sols :</span></span></span></td>
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			<td>{% textarea_tag name=&quot;ddb38851&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Etat du sol&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Etat du sol&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Une &eacute;tude g&eacute;otechnique pr&eacute;alable a-t-elle &eacute;t&eacute; r&eacute;alis&eacute;e ?</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;6dcc3de2&quot; data_label=&quot;Une &eacute;tude g&eacute;otechnique pr&eacute;alable a-t-elle &eacute;t&eacute; r&eacute;alis&eacute;e ?&quot; data_map_field=&quot;nomap&quot;&nbsp;data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Une &eacute;tude g&eacute;otechnique de conception a-t-elle &eacute;t&eacute; r&eacute;alis&eacute;e ?</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;48e0e18d&quot; data_label=&quot;une &eacute;tude g&eacute;otechnique de conception a-t-elle &eacute;t&eacute; r&eacute;alis&eacute;e ?&quot; data_map_field=&quot;nomap&quot;&nbsp;data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Quelles sont les conclusions de l&#39;&eacute;tude au sujet de la qualit&eacute; du sol / praticabilit&eacute; :</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% textarea_tag name=&quot;24753493&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_map_field=&quot;nomap&quot;&nbsp;data_label=&quot;Quelles sont les conclusions de l&#39;&eacute;tude au sujet de la qualit&eacute; du sol / praticabilit&eacute; :&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</span></td>
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			<td style="width: 77%; text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Avez-vous connaissance de suj&eacute;tions (zone argileuse ou nature du sous-sol impliquant des contraintes sur la construction &agrave; &eacute;difier) concernant le terrain ?</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;c11e0f0c&quot; data_label=&quot;Avez-vous connaissance de suj&eacute;tions (zone argileuse ou nature du sous sol impliquant des contraintes sur la construction &agrave; &eacute;difier) concernant le terrain ?&quot; data_map_field=&quot;nomap&quot;&nbsp;data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td style="width: 77%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Un &eacute;tablissement class&eacute; a-t-il &eacute;t&eacute; exploit&eacute; sur le terrain ?</span></td>
			<td style="text-align: right; width: 30%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;aa8c956a&quot; data_label=&quot;Un &eacute;tablissement class&eacute; a-t-il &eacute;t&eacute; exploit&eacute; sur le terrain ?&quot; data_map_field=&quot;nomap&quot;&nbsp;data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Si oui,&nbsp;dangers ou inconv&eacute;nients importants qui peuvent en r&eacute;sulter :</span></td>
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			<td>{% textarea_tag name=&quot;6e713121&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Dangers ou inconv&eacute;nients important&quot; data_help=&quot;Dangers ou inconv&eacute;nients important&quot; data_map_field=&quot;nomap&quot;&nbsp;data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td style="width: 77%; text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Le vendeur est l&#39;exploitant de l&#39;installation : l&#39;activit&eacute; a-t-elle entra&icirc;n&eacute; la manipulation ou le stockage de substances chimiques ou radioactives ?</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;ceb80f29&quot; data_label=&quot;Substances chimiques ou radioactives &quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Substances chimiques ou radioactives &quot; data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td style="width: 77%; text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">&Agrave; votre connaissance, le terrain a-t-il &eacute;t&eacute; pollu&eacute; ? (mat&eacute;riel ou d&eacute;chets enterr&eacute;s ou entrepos&eacute;s)&nbsp;</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;959126a8&quot; data_label=&quot;Terrain polu&eacute;&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Terrain polu&eacute;&quot; data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td style="width: 77%; text-align: justify;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Le terrain a-t-il fait l&#39;objet d&#39;une pollution accidentelle ayant entrain&eacute; une contamination des sols et/ou des eaux ?</span></td>
			<td style="text-align: right;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">{% radio_tag name=&quot;0f7ccfdc&quot; data_label=&quot;Le terrain a-t-il fait l&#39;objet d&#39;une pollution accidentelle ayant entrain&eacute; une contamination des sols et/ou des eaux ?&quot; data_map_field=&quot;nomap&quot;&nbsp;data_choices=&quot;OUI|oui; NON|non; *NC|non communiqu&eacute; non concern&eacute;;&quot; %}</span></td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Historique connu (inondation, mouvements de terrains, avalanches, remblais ou autre) :</span></td>
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			<td>{% textarea_tag name=&quot;1cc390d8&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Historique&quot; data_map_field=&quot;nomap&quot;&nbsp;data_help=&quot;Historique&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-size:8px;"><span style="font-family: ITCAvantGardePro; font-weight: 200;">*NC&nbsp;: non communiqu&eacute; / non concern&eacute;.</span></span></td>
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